Wound documentation is critical for the delivery of effective wound care, the facilitation of care continuity, and proper health data coding. Inaccurate wound documentation can impact the ability to determine the best wound treatment options and the overall wound healing process. Unfortunately,...
By Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS
The measurement of a wound, and the plotting of its size over time, is the only estimate that can be used to accurately predict wound healing. This includes such variables as wound exudate, the presence of necrotic tissue, slough and granulation tissue, as well as undermining and tunneling.
In fact, studies have shown that a reduction in wound size occurring over the first two to four weeks is an independent and statistically significant predictor of wound healing (van Rijswijk, 2013; Bolton, 2008).
Methods of Wound Measurement
What methods are frequently used to measure wounds? Here are some of the most common methods used to measure wounds.
- Greatest length and width method: In this method the greatest length and the greatest width of the wound are measured across the diameter of the wound, from wound edge to the opposite wound edge. Length and width can be multiplied to yield the square area of the wound. This single digit can be compared over time and should decrease if the wound is healing.
- Clock method: In this method, the face of a clock is used to guide measurement. The 12:00 reference position is towards the head of the body, and measurements are thus obtained from 12:00 to 6:00 and from 9:00 to 3:00. Depth can and should be included in both of these methods to provide a 3-dimensional measurement of the wound. To measure depth, gently insert a moistened cotton swab into the deepest part of the wound bed. Grasped the swab at the wound edge or margin and then placed against a ruler for measurement.
- Combination method (combining greatest length and width with clock method): In this method, the longest length and the width perpendicular to the length are obtained and are multiplied together to obtain the surface area. Depth should also be captured.
- Photo documentation: Photos can be taken to document wound healing. However, photos cannot accurately convey wound size unless a ruler is placed along the wound. Photo documentation cannot accurately measure wound depth. Most clinicians use photos as an adjunct to measurement. Remember, if you are taking photos of a client’s wound, it is prudent to have them sign a document giving you permission first.
- Wound tracing: A marker or pen is used to trace the outline of the wound directly onto a sterile transparent sheet or film. It is then a simple matter to compare one measurement to the next. Tracing is relatively painless. However, it can be hard to determine where the wound boundaries lie, making this method less reliable and accurate.
Consistency is Key: Factors in Consistent Wound Measurement
Which method of wound measurement is best? According to various studies, what is more important than the method used is the consistency of wound measurement (van Rijswijk, 2013). In other words, the method used is far less important than ensuring that wound measurement is performed on a regular basis (weekly is recommended). According to Morgan (2012), whichever method you choose you should keep the following in mind:
- When measuring length, your ruler should be placed over the longest length (using the clock face if you are using the clock or combination methods); the head is at 12:00 and the feet are at 6:00
- When measuring width, measure the widest aspect of the wound perpendicular to the length; measure 3:00 to 9:00
- When measuring wounds on the feet, the toes are at 6:00 and the heels are at 12:00
- Always measure in centimeters (cm) as LxWxD
- Length may be smaller than width (i.e. the wound may be wider than it is long)
It is equally important to carefully document your findings. Include the method used to perform your measurement and your findings, noting whether the wound has increased or decreased in size since it was last measured. Consider plotting serial measurements on a graph.
Bolton L. Letter to the editor. Advances in Skin and Wound Care. 2008;21(10):450.
Morgan N. Measuring Wounds. Wound Care Advisor. http://woundcareadvisor.com/measuring-wounds/. Published July 11, 2012.
Sussman C, Bates-Jensen B. Wound Care: A Collaborative Practice Manual. Lippincott, Williams & Wilkins; 2007:127-130.
van Rijswijk, L. (2013). Wound wise: Measuring wounds to improve outcomes. Nursing Center.com. http://www.nursingcenter.com/lnc/JournalArticle?Article_ID=1575606.
About The Author
Laurie Swezey RN, BSN, CWOCN, CWS, FACCWS is a Certified Wound Therapist and enterostomal therapist, founder and president of WoundEducators.com, and advocate of incorporating digital and computer technology into the field of wound care.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.